FACTORS THAT INFLUENCE CANADIAN PRIMARY CARE PROVIDERS’ DECISION TO PRESCRIBE MEDICAL ABORTION by Cheryl A. Cruz B.A., University of British Columbia, 2004 B.N., University of Calgary, 2007 PROJECT SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING-FAMILY NURSE PRACTITIONER UNIVERSITY OF NORTHERN BRITISH COLUMBIA March 2025 © Cheryl A. Cruz, 2025 ii Abstract Purpose. To identify the factors that influence primary care providers in their decision to provide medical abortions. Background. Medical abortion has been commercially available in Canada since 2017, with reduced restrictions on prescribing since 2019. It is a safe and effective option for induced abortion and provides autonomy to pregnant people. Understanding the barriers that exist for primary care providers can help to identify ways to further incorporate medical abortion into practice and increase accessibility for patients. Design. Integrative review. Data sources. Studies were obtained through a search of the electronic databases CINAHL (EBSCO), Medline (OVID), and Google Scholar. Review Methods. The Critical Skills Appraisal Programme (CASP, 2023) checklist was modified to appraise all studies. Themes and study characteristics were elicited for data synthesis. Results. Eight studies were selected for review using inclusion and exclusion criteria. The themes identified were the availability of a community of practice, health equity, educational exposure, stigma, regulatory and funding issues, and interprofessional collaboration. Conclusions. Addressing the themes identified through careful consideration of policy implementation, exposure to medical abortion practice in training, ensuring a community of practice and interprofessional collaboration are important factors in increasing access to medical abortion. iii Table of Contents Abstract ........................................................................................................................................... ii Table of Contents .......................................................................................................................... iii Background .................................................................................................................................... 2 Safety and Efficacy ................................................................................................................................. 3 Patient Autonomy ................................................................................................................................... 4 Health Disparity...................................................................................................................................... 5 Nurse Practitioners ................................................................................................................................. 6 Purpose .................................................................................................................................................... 6 Methods .......................................................................................................................................... 7 Study Design............................................................................................................................................ 7 Search Strategy ....................................................................................................................................... 7 Inclusion and Exclusion Criteria........................................................................................................... 7 Search Results ......................................................................................................................................... 8 Analysis .................................................................................................................................................... 8 Findings.......................................................................................................................................... 8 Study Characteristics ............................................................................................................................. 8 Community of Practice ........................................................................................................................ 10 Promoting Equity ................................................................................................................................. 12 Education............................................................................................................................................... 14 Stigma .................................................................................................................................................... 15 Regulatory and Funding Concerns ..................................................................................................... 16 Interprofessional Collaboration .......................................................................................................... 17 Discussion..................................................................................................................................... 18 Conclusion.................................................................................................................................... 23 References .................................................................................................................................... 25 Appendix A Search Strategy ........................................................................................................ 32 Appendix B Prisma Diagram....................................................................................................... 33 Appendix C Data Extraction and Critical Appraisal .................................................................. 34 1 Factors that Influence Canadian Primary Care Providers’ Decision to Prescribe Medical Abortion Since 1969 abortion has been legal in Canada (Royal Commission on the Status of Woman in Canada, 1970). Since the 1988 Supreme Court of Canada ruling stating that Canadian abortion laws were an infringement to the Charter of Rights and Freedoms (Judgements of the Supreme Court of Canada, 1988) Canada has been one of the few countries internationally without abortion laws (Shaw & Norman, 2020). This ruling was significant in its interpretation of abortion as a health care, rather than a legal issue (Shaw & Norman, 2020). There have been multiple challenges to the right to abortion over the decades, however abortion care has transformed from a highly regulated procedure, only available in hospitals, to a practice that promotes autonomy for pregnant individuals (Shaw & Norman, 2020). Pregnant Canadians now have options concerning who provides their abortion, the practice setting in which they access care, and the type of procedure (Shaw & Norman, 2020). In 2015 Health Canada granted approval for the use of mifepristone for medical abortion, however this did not become available for prescription until 2017 and arrived with severe limitations (Munro et al., 2021; Shaw & Norman, 2020). Initial restrictions included the requirement for physicians to dispense and witness ingestion, mandatory ultrasound to confirm gestational age, specific training requirements, and that medication had to be ingested prior to 49 days gestation (Munro et al., 2021). By 2019 these restrictions had been altered to reflect the evidence and increase abortion access through the implementation of: inclusion of NPs as prescribers; choice in terms of provider education method; pharmacist dispensing; no witnessed ingestion, ultrasound requirement only in cases of uncertain gestational age or suspicion of 2 ectopic pregnancy; and an increase in the maximum gestational age to 63 days (Health Canada, 2025). Abortion reporting is no longer mandatory in Canada, however it is estimated that one third of Canadian women have accessed abortion care during their reproductive life (Norman, 2012; Shaw & Norman, 2020). Abortion access is recognized by the World Health Organization (WHO) as essential to the provision of health as a human right (WHO, 2019). The United Nations Committee on the Elimination of Discrimination against Women (2016) urged the Government of Canada to address gaps in provision of abortion due to primary care providers’ moral objection and unequal distribution of services between provinces and territories. Medical abortion (MA) has the potential to improve abortion access for all Canadians. Optimization of abortion care can only be achieved through a deeper understanding of current barriers and facilitators facing health care providers in Canada. In order to improve access to abortion the following question must be answered: what factors influence Canadian primary care providers in their decision to provide MA? Background The intentional termination of pregnancy using medication is defined as medical abortion (MA) (Costescu et al., 2016). Surgical abortion (SA) involves removal of the pregnancy through the cervix via instrumentation (Costescu et al., 2016). Prior to 2017 the majority of abortions performed in Canada were surgical, performed in specialized clinics and hospitals, with a small portion of MAs administered with the off-label use of methotrexate (Munro et al., 2021). Under Health Canada (2019) regulations MA is approved for use up to 9 weeks gestation. MA using the medications mifepristone and misoprostol was approved by Health Canada in 2015 and became available for commercial use in 2017 (Health Canada, 2025). According to the Society 3 of Obstetricians and Gynaecologists of Canada guidelines prior to receiving MA prescriptions patients must be counselled regarding pregnancy options, confirm gestational age, complete blood work and be screened for any contraindications (Costescu et al., 2016). Follow-up care is recommended between 7-14 days after MA and should include blood work to assess for an appropriate drop in the BhCG (pregnancy hormone level) (Costescu et al., 2016). Safety and Efficacy MA is accepted as a safe and effective tool in efforts to improve abortion access in Canada. The safety and efficacy of MA regimens including Mifepristone was well established through clinical trials and several years of use in other countries prior to obtaining Health Canada approval in 2015 (Gynuity Health Projects, 2017; Kulier et al., 2011; Paul et al., 2009; White & Grossman, 2015). Prior to prescribing MA providers must screen for contraindications (Costescu et al., 2016) including: ectopic pregnancy (Condous et al., 2006), chronic adrenal failure (Davey, 2006), inherited porphyria (Cable et al., 1994), uncontrolled asthma (Sitruk-Ware & Spitz, 2003), or allergy to mifepristone/misoprostol (Hausknecht, 2003). Expected side effects of MA include heavy vaginal bleeding, painful cramping, nausea, diarrhea, vomiting, headache, fever and chills, which are expected to be most bothersome between 3-24 hours after administration of misoprostol (Chai et al., 2013). In clinical trials there were no significant bleeding events, however in anemia surgical abortion is preferred to MA due to shorter duration of bleeding with the surgical procedure (Henshaw et al., 1993). The risk of retained products of conception following MA is higher compared to SA, however this can often be managed expectantly (Gatter et al., 2015). Ineffective MA with continuation of pregnancy is rare and can often be managed with a repeated dose of misoprostol but occasionally requiring SA (Costescu et al., 2016; Jackson et al., 2012). MA does not increase the risk of pelvic organ infection when 4 compared to infection rates in individuals who have undergone spontaneous abortions (Dempsey, 2012) . For people concerned regarding future ability to conceive the evidence regarding MA is reassuring. Studies have found that women who have undergone MA have ovulated within a range of 8-36 days of taking the medications (Schreiber et al., 2011). Many people who have MA have a subsequent pregnancy less than a year following their procedure (Chen et al., 2004). Investigations of pregnancy outcomes in people who have had MA or SA did not find a significant difference in the incidence of preterm delivery or low birth weight between these groups and people with no abortion history (Ngo et al., 2011). Safety in abortion must also be considered in the context of violence perpetrated by antiabortion groups or from partners (Costescu et al., 2016). MA affords people safety in avoiding intimidation from anti-choice groups that may be present surrounding abortion clinics or hospitals (Costescu et al., 2016). For people in abusive relationships, where a partner may be controlling the reproductive health of the pregnant person, MA provides an opportunity to end pregnancy in a way that cannot be differentiated from spontaneous abortion (Gee et al., 2009). All aspects of safety may be considerations for primary care providers who are making the decision to provide MA care. Patient Autonomy Increasing patient autonomy is an important factor in the argument for increasing MA access in the Canadian primary care setting. International studies suggest that more than 80% of pregnant individuals will choose a medical over surgical abortion when both options are available (Rodriguez et al., 2012). Many people choose MA due to the convenience and privacy of being able to choose when and where they complete their abortions (LaRoche & Foster, 2020). The invasiveness of surgical procedures, fear of pain, and perceived lack of privacy 5 accessing abortion clinics or hospitals for Surgical Abortion have been identified as reasons people avoid this method (Robson et al., 2009). The Canadian MA guidelines recommend two appointments with the prescribing provider, bloodwork work prior to the procedure to confirm pregnancy hormone levels (Bhcg) and rule out anemia, and post-procedure blood work or urine pregnancy testing to confirm success (Costescu et al., 2016). Surgical abortion typically involves only one appointment for the procedure (Rodriguez et al., 2012). These factors must be adequately explained to the patient so that they can choose the method that best suits their needs. Increased provision of MA delivered via telemedicine occurred during the COVID-19 pandemic, furthering patient options for abortion care which set a precedent for continued low barrier MA services (Renner et al., 2023). Health Disparity Lack of access to MA is tied to the larger issue of health disparity in Canada. Seventeen percent of Canadians are unattached to a primary care provider (Canadian Institute for Health Information, 2024c). Lower income Canadians and those between the ages of 18-34 are significantly less likely to have a primary care provider (Canadian Institute for Health Information, 2024b). Almost 18% of Canadians reside in rural areas (Statistics Canada, 2022), however only 14% of Nurse Practitioners, 13% of family physicians, and 10% of pharmacists practice in these settings (Canadian Institute for Health Information, 2024a). These disparities in access to health care for Canadians residing in rural or remote locations apply to abortion care as well (Renner et al., 2023). Lack of access to local providers or telemedicine, pharmacies, labs, ultrasound, or emergency care are all unique challenges to Canadians living rural and remote locations who require abortions (Renner et al., 2023). In areas of the country without access to abortion services the cost of travel, particularly if needing to travel outside of one’s home 6 territory or province, can pose a significant barrier (Shaw & Norman, 2020). Health disparity may be a consideration for primary care providers regarding MA. Nurse Practitioners Important voices to consider when examining the issue of MA provision in the primary care setting are those of Nurse Practitioners (NPs). Nurse Practitioners are Registered Nurses who have completed a master’s degree and are trained to independently diagnose and treat many medical conditions (Canadian Nurses Association, 2019). Across Canada Nurse Practitioners have been identified as a part of the solution to the growing lack of primary care providers (Wilson et al., 2021) (Wilson et al., 2021). NP practice is associated with reducing service gaps, increasing health equity, and increased team-based care (Wilson et al., 2021). Nurse Practitioners have been allowed to provide MAs since 2017, making them the first group of health care providers, aside from physicians to engage in the practice (Carson et al., 2023; Stirling-Cameron et al., 2024). As the NP workforce grows there is potential to further reduce inequities in abortion care in Canada. Purpose The purpose of this integrative review is to synthesize the current literature regarding Canadian primary care providers experience of MA since it became available in Canada. The research question is “what factors impact the decision making of Canadian health care providers to incorporate the provision of MA into primary care practice?” Through the synthesis of current MA data implications for future research, education, practice and policy will be identified. 7 Methods Study Design This is an integrative review of research on the experiences of Canadian primary care providers with regard to the commercial availability of MA. The systematic approach to conducting integrative reviews outlined by Whittemore and Knafl (2005) was utilized to devise a clear question for review, a search strategy, data appraisal, data analysis, and interpretation of the findings. Search Strategy Three electronic databases (CINAHL (EBSCO), Medline (OVID), and Google Scholar) were searched. In order to capture research on primary care providers representative of those providing MAs in Canada multiple terms were used for these groups (See Appendix A). Multiple terms for MA and the specific medications used were included in the search strategy (See Appendix A). Studies that investigated the perspectives of primary care providers, future primary care providers, and studies reflecting the current practices of primary care providers regarding MA provision were evaluated for appropriateness for this review. Inclusion and Exclusion Criteria Research reviewed included studies of primary care providers practicing in any province or territory within Canada. The primary care providers represented in the research selected were those licenced to provide MAs in Canada and included Nurse Practitioners, physicians and medical students. All research selected was peer reviewed and published in English. Due to fact that MA with mifepristone became commercially available in Canada in 2017 only studies published between 2017-2024 were included. Studies of the off-label usage of methotrexate for 8 MA were excluded. Studies of healthcare practitioners who are involved in MA but not directly prescribing within Canada at this time, such as pharmacists, midwives and Registered Nurses were excluded. Studies involving MA providers in countries other than Canada were excluded. Search Results A PRISMA flow diagram was adapted from Page et al. (2021) to illustrate the search process used for this integrative review (See Appendix B). A total of 324 articles were found in the original search. Removal of duplicate articles reduced the number to 312 for screening. Screening of abstracts and titles resulted in the removal of 282 articles. Thirty articles were read in full, after applying the inclusion and exclusion criteria, 8 research papers were selected for critical analysis. Analysis This integrative review utilized the Critical Appraisal Skills Programme (CASP, 2023) tools to critically analyze the research. Based on use of the CASP (2023) tools all 8 studies were deemed to be methodologically sound and were included in this integrative review. A table was constructed to compile study characteristics, themes, and analysis of the research (See Appendix C). Findings Study Characteristics The eight articles chosen for review were all published between 2018-2024. The research for this critical analysis consisted of five qualitative studies involving semi-structured interviews (Carson et al., 2023a; Carson, et al., 2023b; LaRoche et al., 2022; Munro et al., 2020; Wagner et al., 2020). Three articles reviewed described cross-sectional research conducted using surveys 9 (Myran et al., 2018; Renner et al., 2023; Stirling-Cameron et al., 2024). Two qualitative articles (Munro et al., 2020; Wagner et al., 2020) described research completed as part of a Canadian Contraception Abortion Research Team (CART), which was based on Roger’s theoretical framework for Diffusion of Innovations (2003). Three studies used a modified version of the CART instrument to collect data specific to NP practice. Stirling-Cameron et al. (2024) conducted surveys of Canadian NPs providing MAs with the modified CART. Carson et al. (2023a; 2023b) applied a critical feminist framework to the CART instrument to conduct and analyze one-on-one interviews of Canadian NPs. Care was taken in these studies to meet measures of credibility, dependability, and transferability (Carson et al., 2023a; Carson et al., 2023b). A limitation cited in multiple papers was the difficulty estimating the composition of the abortion workforce in Canada due to the fact that abortion reporting is optional (LaRoche et al., 2022; Renner et al., 2023; Stirling-Cameron et al., 2024). Therefore it is uncertain what percentage of abortion providers in Canada were captured in the research available for review. The majority of studies noted the care that was taken to ensure participants represented all regions, rural and urban settings, as well as a variety of practice settings (Carson et al., 2023a; Carson et al., 2023b; Munro et al., 2020; Renner et al., 2023; Stirling-Cameron, 2024). Myran et al. (2018) sent survey invitations to all Canadian medical schools, however not every medical school agreed to participate and the authors reported a poor response rate from individual students. A limitation of the LaRoche et al. (2022) study is that it only included health care providers who chose to provide abortions as part of the Medical Abortion Access Project in Ottawa and so may not be generalizable to different settings, such as rural communities, and is 10 not reflective of providers who went on to not provide MAs. The authors of this study did not reference a specific framework they used for designing or analysing their interviews (LaRoche et al., 2022). Community of Practice A theme that emerged in many studies was the importance of a community of practice in the decision to provide MAs amongst Canadian primary care providers. Wagner et al. (2020) conducted a qualitative study of MA providers in Quebec. Through interviews of 25 family physicians and 12 obstetrician-gynecologists themes regarding barriers and facilitators to the practice of MA were explored (Wagner et al., 2020). Providers who were not connected to supportive peers with experience prescribing MA reported that this was a barrier to engaging in MA practice (Wagner et al., 2020). Study participants who were providing MAs identified the guidance and support of peers as an important influence on their decision making (Wagner et al., 2020). The authors disclosed a possible desirability bias in this study (Wagner et al., 2020). The study was conducted in the province of Quebec, where there were additional regulations and delays compared to the rest of Canada, which the authors felt was responsible for participants' perception of more barriers than facilitators in MA implementation (Wagner et al., 2020). Munro et al. (2020) also discussed the significance of providers engaged in practice to influence their peers regarding MA provision. Semi-structured interviews were conducted with Canadian family physicians, NPs, gynecologists, professional college members, advocacy group members, abortion facility staff, and government employees to determine perceived factors affecting the decision to provide MAs (Munro et al., 2020). Knowledge of providers in BC and Ontario combating excessive government regulations on MA was identified as a factor influencing providers in other provinces to follow suit (Munro et al., 2020). Particularly in rural 11 or remote communities the guidance of experienced providers, through email, newsletters or other forms of communication, was cited as a facilitator to providing MAs (Munro et al., 2020). A common theme of Munro et al.’s (2020) study was the momentum built by one provider sharing their successful experience of MA with another provider. A multi-methods study of MA in Ottawa included interviews with primary care providers, who identified a community of practice as a key motivator in the decision to provide MAs (LaRoche et al., 2022). This study describes the Medical Abortion Access Project (MAAP) designed by Planned Parenthood Ottawa, whose mandate included recruiting and supporting primary care providers to provide MAs (LaRoche et al., 2022). Participants in this study reported that the community of practice available to them through MAAP influenced their decision to provide MAs (LaRoche et al., 2022). Having access to the advice of experienced peers in navigating practice and regulatory concerns was reported as a factor in motivating providers to perform MAs (LaRoche et al., 2022). The study sample size was small, including 33 physicians, 5 NPs, and 2 obstetrician-gynecologists (LaRoche et al., 2022). The importance of a community of practice to MA providers was also identified in Carson et al.’s (2023b) feminist qualitative study of Canadian NPs. The sample included 16 NPs who were actively providing MAs and 7 NPs who were not working in this capacity (Carson et al., 2023b). A theme in this study was the experience of NPs both receiving and providing MA mentorship (Carson et al., 2023b). Receiving mentorship was cited as a key reason NPs decided to provide MAs (Carson et al., 2023b). NPs who provided MA education to other health care providers reported that many of these providers went on to incorporate MA into their own practices (Carson et al., 2023b). In the Carson et al. (2023a) qualitative analysis of barriers and 12 facilitators to NP MA practice mentors were reported as being essential for navigating through uncertainty. In the mixed-methods, cross-sectional survey conducted by Stirling-Cameron et al. (2024) NPs who were providing MAs were significantly more likely to report practicing in communities with other NPS and physicians who were also MA providers. NPs studied, regardless of their experience with MA, reported the preference for having a health-care professional to mentor them (Stirling-Cameron et al., 2024). Promoting Equity Many studies identified promoting equity and responding to patient requests for MA as pieces of the decision-making process of Canadian primary care providers. Patient requests for MA were pinpointed by many Quebec providers as being a motivator to begin providing the service (Wagner et al., 2020). Similarly, participants in the LaRoche et al. (2022) study stated that they became MA providers due to demand from their patients. The MAAP clinic logs, which were incorporated into the data for this study, confirmed that requests for MA from patients increased over the course of the study, from 2017-2018 (LaRoche et al., 2022). Many primary care providers surveyed identified their professional duty to ensure equal access to reproductive healthcare as part of their decision to provide MAs (Munro et al., 2020). The recognition that the current MA regimen of misoprostol and mifepristone, as opposed to the off-label use of methotrexate, was safer and more efficacious influenced primary care providers surveyed (Munro et al., 2020). MA providers were also cognisant of the autonomy MA provides due to the fact that patients can complete the procedure on their own time, in their own homes, rather than travelling to hospitals or clinics (Munro et al., 2020). 13 Canadian NP MA providers were particularly influenced by health equity in their interview responses (Carson et al., 2023b). Disparities in abortion access for rural and remote communities was identified as a key motivator for becoming an MA provider (Carson et al., 2023b). As providers working in these communities they reported an onus upon them to ensure patients did not have to travel for care (Carson et al., 2023b). Some NPs reported a feeling of duty as a predominantly female profession to respect the desire of many pregnant people to receive care from other women (Carson et al., 2023b). Equity was largely viewed as a facilitator in the decision-making process for MAs, however concerns regarding timely access to ultrasound and surgical abortion were considerations for providers (Carson et al., 2023a; Munro et al., 2020; Wagner et al., 2020). Some rural and remote providers indicated that they were hesitant to provide MA in the event that more intervention than could be provided in their community was required (Carson et al., 2023a; Munro et al., 2020). The perception that accessing a dedicated surgical abortion clinic would better serve patients was voiced in interviews with some providers (Carson et al., 2023a; Munro et al., 2020). Similarly, prior to updated guidelines regarding administration of Rh immune globulin, providers felt that requiring Rh negative patients to navigate obtaining this treatment negated the benefits of MA (La Roche et al., 2022). In the Renner et al. (2023) study of telehealth delivery of MA provider respondents in the territories were more likely to report barriers in access to lab testing or emergency services for their patients. Respondents practicing in the territories and Quebec indicated that access to ultrasound was a barrier to their care (Renner et al., 2023). Barriers to providing MA through telemedicine were also perceived in ascertaining the mental health of patients and difficulty screening for intimate partner violence or coercion over the phone (Renner et al., 2023). 14 Education The role of abortion education with regard to physicians’ intent to provide medical abortion was explored in a survey of 436 Canadian family practice residents (Myran et al., 2018). Less than half of residents reported that abortion had been discussed as part of their formal education and amongst those who received formal abortion education it was reported this was limited (Myran et al., 2018). Less than a quarter of residents gained experience with abortion during their residency (Myran et al., 2018). Similarly, NPs interviewed in the Carson et al. (2023a; 2023b) studies reported that their exposure to abortion occurred during practicums and not as part of their formal education. There was not a statistically significant difference in the amount of MA education received between practicing and non-practicing NPs, both reporting minimal instruction (Stirling-Cameron et al., 2024). Residents who indicated the intent to become MA providers were found to hold favourable beliefs about abortion, practices social acceptability, and that it would not be difficult to incorporate into family practice (Myran et al., 2018). Gaining experience with abortion during residency was correlated with the intent to incorporate abortion into future practice, this relationship was strengthened with an increase in the reported amount of experience (Myran et al., 2018). Myran et al. (2018) found that there was not a significant relationship between formal instruction regarding MA in medical school and intentions to provide MAs. Some limitations of this study include a low response rate, crosssectional study design, and self-reported outcomes (Myran et al., 2018). The authors acknowledge that longitudinal studies would more effectively evaluate the impact of MA exposure in residency on future practice (Myran et al., 2018). Primary Care Physicians surveyed in Wagner et al.’s (2020) Quebec study reported that educational requirements to prescribe were unclear, messaging from the regulatory college was 15 confusing, and the training programs offered were time consuming. Participants in the Munro et al. (2020) study agreed that MA training presented a challenge to being able to prescribe. Stigma Anti-abortion attitudes among colleagues, administrators, and the public were identified in multiple studies as barriers to the decision to provide MA. MA providers noted a lack of cooperation from staff, administrators and community pharmacists, due to objection to abortion, as a barrier to adopting the practice (Munro et al., 2020). Fear of repercussions from the public prevented many MA providers from making their scope of practice known to the general public, influencing decisions to provide MA to their existing patient population (Munro et al., 2020). This was echoed by the findings of La Roche et al. (2022) where the theme of being targeted as an abortion provider led many to restrict the number of patients they offered MA to. NPs surveyed also reported that abortion stigma impacted the decision to prescribe MA (Carson et al., 2023; Stirling-Cameron et al., 2024). A significant number of NPs who had not incorporated MA into their practices reported fear of protest or hostility as a factor in their decision making (Stirling-Cameron et al., 2024). Participants in the Carson et al. (2023a) study reported that many NPs were hesitant to add their names to MA directories due to fear of backlash, however the acknowledgment that this would have consequences for women who could not find MA providers was expressed. The obligation to fulfill professional responsibilities was cited by MA providing NPs as a reason for persevering through this issue (Carson et al., 2023b). Awareness of pharmacists that refused to stock the medications due to conscientious objection was identified as a hurdle for providers interviewed (Carson et al., 2023b). NPs reported considerations for hiring support staff, loss of potential funding, and repercussions from employers in their decision making process around MA (Carson et al., 2023b). 16 Regulatory and Funding Concerns Although many of the initial barriers to MA provision have been removed the literature suggests that the confusion those barriers created persists. In Quebec there was a one year delay in the availability of MA and extra restrictions on prescribing relative to the rest of Canada (Wagner et al., 2020). Physicians in the Munro et al. (2020) study cited 2017 Health Canada regulations, including physician only prescribing and dispensing, specific educational requirements, witnessed patient ingestion of medication, and mandatory ultrasounds as reasons that they were hesitant or decided not to provide MAs. Primary care providers noted that the rapid easing of these restrictions furthered disinformation and hesitancy to prescribe MAs (La Roche et al., 2022). Another consideration identified by Primary Care Providers in the research was the discrepancy in funding, both between medical versus surgical procedures and interprovincially. All provinces cover the cost of surgical abortion to residents, however in many provinces MA was not covered, creating a financial barrier to many patients (Munro et al., 2020). For physicians, issues with new billing codes further complicated the process of adopting MA practice (Munro et al., 2022). The cross-sectional survey conducted by Renner et al. (2023) found that primary care providers, particularly in the prairie provinces and Ontario, reported difficulty with fees for MA provided through telemedicine. NPs in the Carson et al. (2023b) study noted that NPs felt the fact that they are not paid on a fee for service model was a facilitator to implementation, because NPs are not under the same time constraints as physicians when providing care. 17 Interprofessional Collaboration Primary care providers reported that support from health authority administrators, social workers, nurses, pharmacists, and other staff weighed into the decision to prescribe MAs (Carson et al., 2023a; Carson et al., 2023b; Wagner et al., 2020). There was acknowledgement that MA patients would have better outcomes from a multidisciplinary team and the desire of health care providers to only provide MA services if this could be achieved (Carson et al., 2023a; Wagner et al., 2020). Determining which pharmacies carry the medications was reported to be time consuming and required building relationships with community pharmacists (La Roche et al., 2022; Wagner et al., 2020). Although ultrasound was not always required, study participants did express concern that ultrasound clinics would not facilitate ultrasounds in a timely manner (Carson et al., 2023a; La Roche et al., 2022; Munro et al., 2020; Wagner et al., 2020). The Carson et al. (2023a) study reported that some NPs interviewed had formed relationships with diagnostic imaging staff and physicians who were able to expedite ultrasounds needed to confirm gestational age or pregnancy location and cited these relationships as enablers in their MA practice. There was no statistically significant difference between NPs who provided MAs and those who did not in terms of interdisciplinary practice environment (p=0.578) (StirlingCameron et al., 2024). In British Columbia the College of Pharmacists worked with the College of Physicians and was influential in petitioning Health Canada to change dispensing rules regarding MA (Munro et al., 2020). Primary Care providers in other provinces cited this collaboration as a factor in deciding to pursue MA practice (Munro et al., 2020). In the qualitative study of NPs conducted by Carson et al. (2023b) participants discussed the leadership role they took on in hiring pro-choice staff and educating other health care professionals to support MA practice. 18 Discussion The question this review set out to answer was what factors impact the decision making of Canadian health care providers to incorporate the provision of MA into primary care practice? The research reviewed suggests that primary care providers are influenced by the availability of a community of practice, health equity, educational exposure, stigma, regulatory and funding issues, and interprofessional collaboration when deciding to perform MAs. This study adds a unique perspective to the existing literature by pulling together the various perspectives of physicians and NPs throughout Canada regarding this topic. The importance of being connected to a community of practice and interprofessional collaboration were common themes in the majority of studies. This emphasizes the importance for professional colleges to ensure their members are aware of the resources available to them. Providers are far more likely to engage in MA practice when they feel that they are not working in isolation (Carson et al., 2023a; Carson et al., 2023b; LaRoche et al., 2022; Munro et al., 2020; Stirling-Cameron et al., 2024; Wagner et al., 2020). This finding also has important implications for NP practice. NP competencies emphasize our role as leaders and collaborators in patient centred care (Canadian Nurses Association, 2019). NPs are in a position to provide leadership in mentorship within multidisciplinary teams to encourage and support other providers to incorporate MA into practice. Both Carson et al. (2023b) and Stirling-Cameron et al. (2024) provided examples of NPs taking on mentoring roles and influencing hiring practices to support MA practice. The British Columbia Ministry of Health (2025) has committed to increasing the number of primary care networks throughout BC, consisting of multidisciplinary teams, including physicians, social workers, registered nurses, and NPs. This announcement has the 19 potential to strengthen MA practice as primary care networks will bring multiple healthcare practitioners into a worksite, allowing for greater interdisciplinary collaboration. MA provides exciting possibilities to equalize access to abortion across Canada, however findings of this review reveal that the barriers to abortion are inextricably linked to existing service gaps for Canadians in rural and remote communities. NPs and physicians who participated in these studies were both committed to providing MAs and concerned about the implications of providing services with no safety net (Munro et al., 2020; Wagner et al., 2020). Communities without access to urgent care, emergent care, or diagnostic tools pose a moral dilemma to primary care providers who want to facilitate safe, local abortion care to their patients (Renner et al., 2023). Carson et al. (2023a) points to a disarticulation between MA in primary care practice and MA policy, for example in the difficulty obtaining medications or accessing timely diagnostics in some communities. These findings should inform policy makers to ensure adequate infrastructure exists to support best practices. Professional regulatory bodies should also ensure they are adequately communicating scope and policy information relevant to MA practice (Carson et al., 2023a). This review found that abortion education in medical and NP training was a factor in the decision to provide MA. Although only one paper on medical education and abortion was reviewed, the finding that there was a statistically significant relationship between informal abortion training and intent to practice abortion, and no statistically significant relationship between formal training and intent to practice, has implications for further research and education (Myran et al., 2018). Myran et al. (2018) suggested that longitudinal studies would inform the research regarding whether intent to practice MA in residency resulted in adopting the practice after graduation. Although there was not a statistically significant difference (p=0.578) 20 between NPs who provided MA versus those that did not in terms of MA education (StirlingCameron et al., 2024), all NPs reported minimal MA training as part of their program (Carson et al., 2023a; Carson et al., 2023b; Stirling-Cameron et al., 2024). To ensure awareness of full NP scope in relation to reproductive health care Carson et al. (2023a) recommends more robust NP education including practicums in clinics that provide MA. With regard to professionals already in practice this review suggests that professional regulatory bodies should ensure that they are accurately communicating education requirements for practice to their members (Munro et al., 2020; Wagner et al., 2020). This review found that abortion education in medical and NP training was a factor in the decision to provide MA. Although the study only reviewed one paper on medical education and abortion, the finding that informal abortion training was more significantly associated with intent to practice compared to formal training has implications for further research and education (Myran et al., 2018). Myran et al. (2018) suggested that longitudinal studies would inform the research regarding whether intent to practice MA in residency resulted in adopting the practice after graduation. Although there was not a statistically significant difference between NPs who provided MA versus those that did not in terms of MA education (p=0.578) (Stirling-Cameron et al., 2024), all NPs reported minimal MA training as part of their program (Carson et al., 2023a; Carson et al., 2023b; Stirling-Cameron et al., 2024). To ensure awareness of full NP scope in relation to reproductive health care Carson et al. (2023a) recommends more robust NP education including practicums in clinics that provide MA. With regard to professionals already in practice this review suggests that professional regulatory bodies should ensure that they are accurately communicating education requirements for practice to their members (Munro et al., 2020; Wagner et al., 2020). 21 Abortion stigma continues to be a factor in the decision making of MA providers. Amongst providers performing MA many were concerned for their safety if they advertised this service (Carson et al., 2023a; Carson et al., 2023b; La Roche et al., 2022; Munro et al., 2020; Stirling-Cameron et al., 2024). Although fear of repercussions is relevant, it adds to the abortion seeking public's confusion around where to access MA. Fear of stigma ties into the importance of having a visible and accessible community of practice for abortion providers. Study participants indicated that the fear of being singled out as an abortion provider was often alleviated when they became aware of other providers offering MAs (LaRoche et al., 2022; Munro et al., 2020). Although healthcare professionals have the right to decline to provide care that they find morally objectionable they are not permitted to abandon their patients. The Canadian Nurses Association’s (CNA) code of ethics (2017) clearly establishes the expectation that nurses and NPs notify their employers of moral objections and promptly refer patients to a provider who can provide care. The fact that so many providers cited stigma as a factor in MA provision indicates that many healthcare providers, administrators, and support staff are not taking their ethical duty to provide care, despite conscientious objections, seriously. Within health authorities and primary care networks it is important that policies reflect this obligation so that people have timely access to MA, without facing discrimination. Myran et al. (2018) acknowledges that rights of providers to abstain from training in the field of abortion but recommends that practical opportunities in MA practice are beneficial in reducing stigma. The majority of studies indicated that primary care providers were confused by rapidly changing policies and a lack of clarity regarding funding for MA (LaRoche et al., 2022; Munro et al., 2020; Renner et al., 2023; Wagner et al., 2020). These findings emphasize the importance 22 of ensuring health policy is evidence based and clearly communicated with professional bodies prior to making a medication commercially available. In approving MA and making it commercially available, prior to putting fee codes into place or anticipating logistical problems in its implementation, Health Canada created barriers that impacted Canadians seeking abortion. Disparities between provinces and territories regarding the cost of MA is something that must be addressed within Canada in order to obtain equitable abortion care. Carson et al. (2023b) recommends that policy makers collaborate with administrators, healthcare professionals and allied health professionals to implement plans that are equitable interprovincially/territorially, improve education and increase equity. The theme of interprofessional collaboration as an important factor in MA decision making has implications on several levels. From a practice perspective this theme stresses the importance for MA providers to be aware of resources in their community and to reach out and build connections. Although radiologists, booking clerks, pharmacists, nurses and social workers are not prescribing the MA their collaboration is essential to timely, patient centred abortion care (Carson et al., 2023a; Stirling-Cameron et al., 2024). Policy and education from within health authorities that fosters collaboration between these groups would be beneficial to MA care. One limitation of this review is that most of the research was conducted prior to policy changes that occurred in 2019, lessening restrictions, therefore it is unclear if the practice landscape has changed since that time. Although the majority of research selected included representation from all regions of Canada, the most populous provinces were overrepresented, and due to the lack of mandatory abortion reporting in Canada it is difficult to estimate if the research was truly representative of abortion providers nationally. Although a great deal of research exists explaining the safety, efficacy and benefits to patients who undergo MA, there is 23 a paucity of research investigating what influences the decision to provide MA. The majority of research I reviewed asked more specifically about barriers or facilitators to practice and did not collect data specific to my research question. My review involved a search of three databases and may have missed some studies germane to my research question. Conclusion The aim of this integrative review was to explore how to increase access to medical abortion in Canada. The question this review set out to answer was “what factors influence the decision to prescribe medical abortion among Canadian primary care providers?” The databases used to identify studies were CINAHL (EBSCO), Medline (OVID), and Google Scholar. Using the integrative review framework described by Whittemore and Knafl (2005) studies were selected, critically appraised, and thematically analyzed for synthesis of the data. The themes that arose from reviewing the current research include the influence of a community of practice, health equity, educational exposure, stigma, regulatory and funding issues, and interprofessional collaboration. This review suggests important implications for future research, policy, education and primary care practice. Addressing the issues that influence primary providers is vital to improving MA access to Canadians. The current shift in British Columbia towards increasing primary care networks is a potential facilitator for MA access in that they will provide opportunities for interprofessional collaboration, mentorship, and connection with communities of practice (British Columbia Ministry of Health, 2025). This review underlines the importance of clear communication of scope, policy, and guidelines when implementing new processes (Carson et al, 2023a; Wagner et al., 2020). Implications for education that were illuminated by this review include the value of MA training in residency and practical experiences (Myran et al., 2018) and clear 24 communications of educational requirements for practice (Munro et al., 2020; Wagner et al., 2020). This review was limited by the fact that policy and guidelines were rapidly changing at the time that the majority of the studies cited were being conducted (Health Canada, 2025), therefor further study regarding the current MA landscape would be beneficial. 25 References Cable, E. E., Pepe, J. A., Donohue, S. E., Lambrecht, R. W., & Bonkovsky, H. L. (1994). Effects of mifepristone (RU‐486) on heme metabolism and cytochromes P ‐450 in cultured chick embryo liver cells. 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Who.int; World Health Organization: WHO. https://www.who.int/health-topics/abortion#tab=tab_1 32 Appendix A Search Strategy Search Date Database Search Terms Articles Retrieved DEC 2024 CINHAL (EBSCO) (“Nurse Practitioner” or “NP student” or “general practitioner” or “family physician” or resident, or “medical student” or “general practice” or “family practice” or “primary care” or primary health care”) AND (“medical abortion” or “induced abortion” or “early term abortion” or mifepristone or mifegymiso) 9 DEC 2024 Medline (OVID) (“Nurse Practitioner” or “NP student” or “general practitioner” or “family physician” or resident, or “medical student” or “general practice” or “family practice” or “primary care” or primary health care”) AND (“medical abortion” or “induced abortion” or “early term abortion” or mifepristone or mifegymiso) 288 DEC 2024 Google Scholar “primary care practice”, Canada, “medical abortion” 27 33 Appendix B Screening Identification Prisma Diagram Records identified through: Database searching (n= 324) CINHAL (EBSCO): 9 Medline (OVID): 288 Google: 27 Records removed before screening: Duplicate records removed (n = 12) Abstracts/Records screened with inclusion criteria. (n = 312 ) Articles/records excluded (n =282 ) Full-text articles sought for retrieval (n = 30) Articles not retrieved (n =0 ) Included Full-text articles assessed for eligibility (n =30 ) Records included in review (n = 8 ) Qualitative: 5 Cross-sectional: 3 Records excluded: Reason 1 (n = 22) Reason 2 (n = ) Reason 3 (n = ) etc. 34 Appendix C Data Extraction and Critical Appraisal Data Extraction Authors Wagner, Marie-Soleil; Munro, Sarah; Wilcox, Elizabeth; Devane, Courtney; Norman, Wendy; Dunn, Sheila; Soon, Judith; Guilbert, Edith Title Barriers and Facilitators to the Implementation of First Trimester Medical Abortion With Mifepristone in the Province of Quebec: A Qualitative Investigation Year 2020 Journal Journal of Obstetrics and Gynaecology Canada Record # 1 Study Type Qualitative Methodology Observational, prospective, mixed-methods-Interviews # of participants 37 Characteristics of Participants 25 (67.6%) family physicians, 12 (32.2%) OB-GYNs Age: <39=13 (35.2%), 40-49=7 (18.9%), 50-59=9 (24.3%), 60+=8(21.6%) Female=30 (81.1%), Male=7 (18.9%) Phenomena of Interest Barriers and Facilitators to the implementation of 1st trimester MA Setting (Culture, geography) Practice setting: Urban 14 (37.8%), Rural 13 (35.2%), Remote 10 (27%) All practicing in the province of Quebec Outcomes, Themes & Subthemes Barriers: Uncertainty or confusion about practice policies regarding MA lack of human resources or support from colleagues, uncertainty about product distribution (lack of timely/efficient distribution mechanisms), confusion about professional collaboration (lack of interprofessional collaboration both individual and organizational level, pharmacists, feelings of isolation), lack of local infrastructure (concern re lack of access to timely u/s or d & c if complications arise) Facilitators: Perception of support and influence from colleagues (organizational culture, communities of practice, mentorship), previous experience with MA, requests received from patients or other doctors, being aware of MIFE research Author’s Conclusions The greatest barrier to MA in Quebec was the initial policy requiring additional training and u/s. Reviewer’s Comments Although the major finding of this study is only applicable to Quebec there are themes in this study that are applicable across Canada. Critical Appraisal Was there a clear statement of the aims of the research? Yes. The goal of the research was to identify barriers and facilitators encountered by physicians in Quebec who were capable of providing MAs. This was identified as an important study because MA was identified as a means of making abortion available to women in areas of the country where access was limited. Quebec physicians faced additional barriers to MA prescribing initially, including a 1 year delay compared to the rest of Canada. Is a qualitative methodology appropriate? Yes. Qualitative methodology was appropriate because the study sought to explore issues physicians identified as barriers or facilitators to providing MAs. 35 Was the research design appropriate to address the aims of the research? Yes, the interview guide and analysis were based on the diffusion of innovation theory. Was the recruitment strategy appropriate to the aims of the research? Yes, the study was embedded within a larger mixed-methods study. Family physicians (FPs) and OB-GYNs in active practice, with experience providing abortions (members of the Association of Quebec abortion providers) were invited to participate in interviews. Email invitations were sent to those who had participated in the larger study and consented to follow up interviews. There was also recruitment through an online community of practice where participants were encouraged to share study information with other providers. All participants would have demonstrated an interest in abortion care or providing the service so this study would not capture the reasoning of FPs or OB-GYNs who were not engaged in abortion care. Was the data collected in a way that addressed the research issue? Yes. Interviews were conducted by phone using open-ended questions about potential barriers and facilitators to MA services. A semi-structured interview guide used the theory of the diffusion of innovation. Demographic information was collected using a 10 item questionnaire. Interviews were audio recorded and transcribed, with identifiers removed before analysis. Interviews were collected until theoretical sufficiency (no new theoretical insights were revealed) Has the relationship between researcher and participants been adequately considered? The researchers mention a possible “desirability bias” due to the fact that all participants were engaged in some way with abortion care or showed interest in providing this care. The researchers conducting interviews were both physicians with experience providing abortion services. There was no mention of changes in the research design. Have ethical issues been taken into consideration? Yes, the study was approved by the Institutional Review Board of UBC. Confidentiality was maintained by removing personal identifiers from transcripts. Was the data analysis sufficiently rigorous? Yes, independent duplicate analysis of transcripts, guided by thematic analysis was used to produce a coding framework through inductive analysis. Number of participants, quotes for each theme and subtheme, conflicting opinions, and the absence of barriers and facilitators in different contexts were analyzed. The researchers did not specifically address their own role or potential bias. Is there a clear statement of findings? Yes, barriers to implementation were more commonly experienced than facilitators. Barriers included uncertainty regarding practice policies, lack of support from colleagues/community of practice, uncertainty about product distribution, confusion about professional collaboration (pharmacists), lack of local infrastructure (access to u/s aspiration if complications). Facilitators were described as perceived support and influence from colleagues (mentors). How valuable is the research? This research was conducted in Quebec where there were unique barriers to MA in 2017, which have now been removed. Initially the College of Physicians of Quebec (CMQ) imposed mandatory training or proof of experience prior to providing MAs. As a consequence there was increased confusion and lower uptake of MA provision relative to provinces such as BC. However, there are additional barriers and facilitators identified that are common to all providers in Canada. I believe that this research is useful for Primary Care Providers across Canada in evaluating why these providers do or do not provide MAs. • Appraisal Summary Key Points • • • Open-ended questions illicit many perspectives relevant to the issue Recruited through a lot of different organizations and represented all health regions in Quebec. Study designed by abortion providers represented issues relevant to practice. Identification of barriers and facilitators, and contradictory results Desirability bias, study would have greater reach if it polled all Primary Care Providers rather than those already engaged in MAs Small sample size Data Extraction Authors Myran, Daniel; Bardsley, Jillian; El Hindi, Tania; Whitehead, Kristine Year 2018 Journal BMC Record # 3 36 Study Type Quantitative Methodology 21 item survey. Cross sectional # of participants 436, after exclusion 413. Characteristics of Participants Residents from Several ON universities, Sask, U of A and UBC. Mean age 29.62 29.9% male, 70.1% female Intended practice location: Rural (<9999) 15.5%, Small town (10,000-99,999) 60.9%, urban 23.6% Year of training: 1- 48.6%, 2-48.7%, 3-2.7% Religious/moral objection to abortion: Yes 17.99%, No 82.1% Phenomena of Interest To examine Canadian medical school education re abortion, exposure to abortion in residency, intention of residents to provide abortion and self-assessed competence in the area Setting (Culture, geography) English speaking medical residency programs in BC, Sask, Alberta, and Ontario. Outcomes, Themes & Subthemes There is a lack of education provided to fam practice residents in Can re abortion. Most residents held pos beliefs re abortion and thought that it should be included in training. Lack of statistical significance between formal abortion education and intention to practice. Informal training showed stat significance in association with intent to practice. Exposure to MA in training were more likely to intend to practice MA, believed it was part of scope. Author’s Conclusions Positive perceived social norm and anticipated ease of provision associated with intent to incorporate into practice. Authors believe that department of fam medicine need to focus on decreasing stigma around abortion, increase competency and improve social norms by creating opportunities for exposure to abortion in clinical placements. Critical Appraisal Was there a clear statement of the aims of the research? To examine the amount of education and exposure medical residents receive to abortion. To assess attitudes, intentions and competency around intention to provide abortion care. Examine the association between attitudes, social norms, and perceived difficulty to initiate practice with intent to provide abortion. To investigate that relationship between education and exposure on plan to provide abortion in practice. Is the methodology appropriate? Yes, measures of types and amount of exposure to medical abortion in education, intent to practice MA. Was the research design appropriate to address the aims of the research? Theory of Planned Behaviour (TPB) used to design survey. Theory asserts that intention is a strong predictor of future behaviour and is informed by attitudes, perception of social norms and perceived competence. Questions from previous surveys on abortion education were adapted using this theory. Was the recruitment strategy appropriate to the aims of the research? Yes, all English based family medicine residency programs in Canada were contacted. Programs that did not respond were not included in study. Schools representing slightly less than ½ of residents participated (46.5%). Residents were emailed survey invitations, in-class announcements and social media posts. Fam medicine programs sent out emails or included survey information in news letters. Incentive provided ($20 GC) Was the data collected in a way that addressed the research issue? Yes, but limitation in cross-sectional design, low response rate and self-reported outcomes. Authors concede that residents may not be capable of ranking their own competence. Inability to establish causal relationship, propose longitudinal study of residents as they progress through training. Has the relationship between researcher and participants been adequately considered? Yes, anonymous online surveys. Have ethical issues been taken into consideration? University of Ottawa and University of Alberta Research Ethics Boards approval. Was the data analysis sufficiently rigorous? Chi-square tests to establish relationship between exposure to abortion and intention and self expressed competency. P values were reported. 37 Is there a clear statement of findings? Yes, established that there is little formal or informal MA training in Canadian fam practice residency programs. Indicates that informal training, during clinical placements, increases provider intent to incorporate MA into practice and increases perceive competence. How valuable is the research? Valuable in that it confirms a need to increase fam practice medical students exposure to MA. Appraisal Summary Key Points Speaks to importance of exposure of health care students to medical abortion through clinical placements. Inadequate training provided in medical programs and residents feel a lack of confidence. Data Extraction Authors Munro, Sarah; Guilbert, Edith; Wagner, Marie-Soleil; Wilcox, Elizabeth; Devane, Courtney; Dunn, Sheila; Brooks, Melissa; Soon, Judith; Mills, Megan; Leduc-Robert, Genevieve; Wahl, Kate; Zanniet, Erik; Norman, Wendy Title Perspectives Among Canadian Physicians on Factors Influencing Implementation of Mifepristone Medical Abortion: A National Qualitative Study Year 2020 Journal Annals of Family Medicine Record # 4 Study Type Qualitative Methodology Semi Structured interviews. Data collection and thematic analysis guided by Diffusion of Innovation theory. # of participants 90, 45 family physicians, 8 gyn, 2 other PCP, 13 college representatives, 9 advocacy group members, 7 government, 6 abortion facility. Characteristics of Participants Physicians who intended to begin MA pracitice within the 1st year of availability, such as family physicians. Stakeholders such as health care professional colleges, Health Canada representatives. English or french speakers. Phenomena of Interest Factors that influence the initiation and provision of AM in Canadian physicians and stakeholders. Setting (Culture, geography) Canadian health care settings-anywhere primary care can be provided including hospitals, abortion clinics, health centers, private physician offices and telemedicine. Largest proportion of participants were from Qu, then BC, ON, some representation from prairie, maritime, and territories. Outcomes, Themes & Subthemes 1)Federal restriction made by health Canada overly complicated the initial uptake of MA practice. Initial training was time consuming, registration with manufacturer was a perceived breach of privacy. Initially physicians had to dispense which was out of scope. U/S was an initial requirement which was a barrier to many communities (rural/remote). This was particularly true for PCPs working outside of hospitals or abortion clinics. Initially observed dosing requirement-Paternal. Despite removal of many restrictions within 1st year perception of many physicians was that these remained! 2) Navigating bureaucratic processorganizational barriers. Lack of consistency in provincial funding, building billing codes. Conscientious objectors, anti choice attitudes within organizations, hospital staff who made process difficult, pharmacists who refused to carry or dispense med. Contributed to geographic variation in implementation. Stigma influenced how much many were willing to communicate or advertise the service. Many barriers in Quebec. BC and ON identified as examples of where health professional colleges had overruled Health Canada restrictions and allowed pharmacists to dispense to patients. Leading by example. Vast geographic catchments in rural communities. Concerns about loss to follow up with multiple visits required for MA. Participants did identify having experienced peers to guide them through fears around potential complications. 3) Challenges with diffusion and dissemination of policy info-lag between Health Canada changes and product monograph update. Rapid changes to restrictions left many confused. Peers were identified as critical, especially to rural prescribers. Canadian Abortion Providers Support (CAPS) platform biweekly emails were sited as a good source of info. Need for more public communication to family physicians and public to raise standard of care. Practitioners felt a sense of responsibility to support access to reproductive care. 4). There had to be awareness of mifepristone, access to up to date info, and have an idea of how it would benefit their practice and patients. Confidence in the practice increased with each 38 successful MA. Perception of benefit of mif over methotrexate abortion was a facilitator. Barrier for urban prescribers was the perception that there was adequate accessibility in their community. Author’s Conclusions Federal regulations are barriers to the uptake of mife. Some perception that MA is riskier than it is despite evidence that it is lower than risk of continued pregnancy. Critical Appraisal Was there a clear statement of the aims of the research? Yes, the aim of the study is to identify factors that influence the initiation and provision of MA from the perspectives of Canadian physicians and stakeholders. This is important due to the paucity of family planning services available to Canadians. Is a qualitative methodology appropriate? Yes, it sought to explore the experiences and perceptions of physicians and stakeholders related to MA Was the research design appropriate to address the aims of the research? Yes, guided by Rogers’ theory of the Diffusion of Innovations. This was one part of a 4 year mixed methods, prospective study. Semi-structured interviews pilot tested with researchers and clinicians prior to data collection. Was the recruitment strategy appropriate to the aims of the research? Invitations were provided to participants in the Contraception and Abortion Research Team-Mifepristone (CART-Mife) online survey in 2017, these were physicians who intended to begin providing MAs. Nonproviding health care professionals and stakeholders were invited through 3rd party recruitment (eg health professional organizations). Physicians were also asked to refer potential participants (snowball recruitment). Stratified purposeful sampling to ensure diversity or participants. Was the data collected in a way that addressed the research issue? One on one semi-structed interviews via telephone at onset of availability of mifepristone (2017). Repeat interviews one year later. Interviews repeated until saturation was achieved and data was repeated. Verification strategies were implemented. Audio recordings. Has the relationship between researcher and participants been adequately considered? Considered participants comfort level and differences in power and status. Participants were assigned unique identifieers and coded. Have ethical issues been taken into consideration? Ethical approval provided by the Behavioral Research Ethics Board of the University of BC and BC Women’s and Children’s Hospital. Was the data analysis sufficiently rigorous? Transcribed and French interviews translated to English. 2 researchers completed thematic analysis using Braun and Clarke’s flexible approach. Discrepancies were resolved with a third team member. Mapped themes to constructs in Diffusion of Innovation theory. Individual, organizational and system patterns, relationships and interactions between codes were explored. Conflicting themes were considered. Analysis was written into a descriptive, explanatory narrative Is there a clear statement of findings? Yes, all themes were explored including contradictory themes ie: for urban locations those who did not intend to provide MA perceived that there was a lack of need for MA in their communities due to adequate reproductive health services. How valuable is the research? Very, it has implications for increasing access to MA, particularly for rural and remote communities. Appraisal Summary Key Points Strengths of study were applicability to other high-income countries, national sample, interviews at 2 points in time, perspective of both new and experienced providers, physicians not involved in MA care, stakeholder input. Included those from regions with limited access. Limitations: only 1 NP sampled. Data Extraction Authors LaRoche, Kathryn; Wylie, Ariane; Persaud, Mira; Foster, Angel Title Integrating mifepristone into primary care in Canada’s capital: A multi-methods exploration of the Medical Abortion Access Project Year 2022 39 Journal Contraception Record # 5 Study Type Qualitative Methodology Multi-methods evaluation # of participants 15 family physicians, 3 NPs, 1 OB-GYN Characteristics of Participants Family physicians, NPs and OB-GYNs in Ottawa providing MA in 2017-2018 Phenomena of Interest Report on the outcomes of the Planned Parenthood Medical Abortion Access Project (MAAP), identify barrier and facilitators, and determine factors that support PCPs in providing MAs Setting (Culture, geography) Ottawa Outcomes, Themes & Subthemes Barrier: Information-changing product monograph, shifting regulations, initial requirement to dispense directly to patients overly complicated process. Many restrictions lifted from 2017-2019 but this created confusion for patients and providers. Logistical issues: finding a pharmacy that caries MA drugs, access to rapid u/s when necessary, accessing WinRho when needed for Rh neg patients. Additional burdent to Rh neg patients with added appointments and travel to hospital. Privacy and stigma concerns re: being identified as an abortion provider. Eb and flow of demand- clinicians identified challenge to manage their schedules due to difficulty anticipating demand. Facilitators: Patient demand MAAP served as a centralized resource for MA providers and became a community of practice. Helped providers feel supported and encouraged to continue practicing. Author’s Conclusions Community of practice was vital to supporting clinicians to take on the practice of MAs. Critical Appraisal Was there a clear statement of the aims of the research? To report on the outcomes of Planned Parenthood Ottawa’s (PPO) MAAP and to identity barriers and facilitators to implementation of MA, and to discuss implications for the rest of Canada. Is a qualitative methodology appropriate? Yes, semi-structured interviews were appropriate to determine factors PCPs identified as barriers and facilitators to MA Was the research design appropriate to address the aims of the research? Maybe, researchers did not discuss how they determined the method used. Was the recruitment strategy appropriate to the aims of the research? The authors did point out that only clinicians who decided to prescribe MAs were interviewed. They were several clinics who expressed interest in getting involved who did not follow through, therefor the perspectives of those who chose not to prescribe MAs was not explored. Was the data collected in a way that addressed the research issue? Yes, the interviews evaluated barriers and facilitators as identified by prescribers. As discussed above the research did not explore reasons why people did not participate. Has the relationship between researcher and participants been adequately considered? There is no apparent power-dynamic between researchers and participants. Have ethical issues been taken into consideration? Approved by Social Science and Humanities Research Ethics Board of University of Ottawa and The PPO Executive team. Was the data analysis sufficiently rigorous? This is not addressed. Common themes are discussed but researchers do not address data saturation. 40 Is there a clear statement of findings? Yes, barriers to prescribing include confusion over initial restrictions/rapid changes to restrictions, logistical concerns (pharmacies, u/s, Win-Rho), stigma. Faciliatiors include patient demand and community of practice How valuable is the research? This data does provide an insight into challenges faced by MA prescribers in Canada, although it only studied providers in a large urban centre in Canada so may not be applicable to rural locations. Small sample size. Does not reflect barriers to smaller rural or remote communities. Appraisal Summary Key Points Community of practice is key to supporting providers. Data Extraction Authors Carson, Adrea; Cameron, Emma; Paynter, Martha; Norman, Wendy; Munro, Sarah; Martin-Misener, Ruth Title Nurse practitioners on ‘the leading edge’ of medication abortion care: A feminist qualitative approach Year 2023b Journal Journal of Advanced Nursing Record # 6 Study Type Semi-structured interviews Methodology Qualitative interviews # of participants 4320 stakeholders, 16 NPs providing abortion care and 7 NPs who did not provide abortions. Characteristics of Participants 20 stakeholders, 16 NPs providing abortion care and 7 NPs who did not provide abortions. NPs: 20 Female, 3 male. Remote 1, Rural 6, Urban 16. Practice type: primary care 14, sexual health 4, Women’s health 5. Stakeholders were decision makers in health policy systems related to MA. Phenomena of Interest The experiences of NPs in Canada regarding MA implementation. Strategies to support implementation Setting (Culture, geography) Canadian provinces and territories. NP communities Remote 1, Rural 6, Urban 16. Outcomes, Themes & Subthemes 1)Facilitating implementation: None of the NPs interviewed had received abortion training in their formal education. NPs sought out the practice, developed protocols, mentored colleagues, provided education to other health providers, networked with lab techs, allied health to expedite required appointments. Leadership, leading by example. Mentorship from colleagues was also crucial to beginning practice. Mentorship built confidence and provided support for new providers. Lack of mentorship was sited as a reason some did not yet provide MAs. 2)Navigating resistance- Lack of support from colleagues, employers due to stigma of abortion affected implementation. Many tried to combat this with education re professional responsibilities, or working around these obstacles. Some pharmacies refused to stock so NPs had to be aware of pharmacies that would stock and build relationships with these pharmacies. Hiring practices of clinics: specific interview questions re pro choice. Hierarchies/Discrimination in some communities of NP u/s reqs not receiving same priority as physicians. Lack of recognition of NP knowledge and expertise even within healthcare. Some NPs hesitant to advertise the service widely due to stigma. Concern over pulling funding by employers within private clinics. IE: refusal to fund POC u/s due to its use for MAs. Politics despite health canada support for process. 3) Promoting equity and normalizing abortion in primary care: Value of NPs in abortion care, fill primary care gap, particularly in rural/remote. NPs improve access by increased number of providers and access to care closer to home. Patient trust for NPs. Lack of fee for service payment =increased time spent with patients, increased time to answer questions and impart info. Importance of building MA into primary care and providing service to patients that are known to the NP. Greater number of female NPs, more woman comfortable with receiving MA from females. NPs reported that they provided more efficient MA care to their patients, being aware of importance of timely care. Feminist care. 41 Author’s Conclusions Feminist framework used to understand how NPs navigate social stigma, health system resistance, health professional hierarchies to provide MA care. NPs are leaders in this field, trusted by their patients and ideally situated to address socio-cultural barriers to the process. Critical Appraisal Was there a clear statement of the aims of the research? Yes, to explore nurse practitioners’ experiences of medication abortion implementation in Canada and to identify ways to further support the implementation of MA by NPs in Canada. It is important due to the role of MA in providing patients with more autonomy over their health care decisions. Is a qualitative methodology appropriate? Yes, qualitative research is appropriate to explore this issue. Allows for deeper reflection on an evolving practice. Was the research design appropriate to address the aims of the research? Yes interviewing NPs that were involved in MA and not provided perspective on challenges to prescribing and reasons NPS were not prescribing. It was informed by critical feminist theory to examine the impact of social structures on practice. Was the recruitment strategy appropriate to the aims of the research? Health professional organizations/societies, snowball sampling, and participants in the CART NP survey. Emails sent via health professional organizations. Snowball sampling was done at the end of each interview. Was the data collected in a way that addressed the research issue? Interview was designed to gain data on participants experience with MA, perception on implementation, impact on patients and community, and challenges to practice. Non-providing NPs were asked about motivation to provide or not provide. Stakeholder questions captured legislative, regulatory and scope of practice issues. Investigators met several times to review and revise questions. Has the relationship between researcher and participants been adequately considered? This was not addressed. There was no remuneration for participation Have ethical issues been taken into consideration? Approval by Nova Scotia Health and UBC. Interviews in English or French. Informed consent ensured prior to participation. Was the data analysis sufficiently rigorous? Interview answers were analysed for recurring ideas and concepts including inconsistencies and contradictions. Interviewers wrote memos of interviews re key takeaways. Research team would meet weekly to review memos and adjust questions or approach. Two researchers would read transcripts multiple times and categorize data. After coding researchers would write analytic memos. Measures were taken to ensure credibility, dependability and transferability of data. Is there a clear statement of findings? Yes, using critical feminist perspective 3 major themes were identified related to how NPs experience MA implementation.. 1) educating, mentoring, and networking with other health providers in the community, 2) working around resistance from colleagues/employers/public to MA provision, 3) integrating health equity principles into MA provision and advocating for abortion in primary care How valuable is the research? The value of this research is that it explores barriers and facilitators to NPs involvement in MA care. Integrating NPs into this practice will improve equity and access to MA, particularly in rural, remote and underserved communities. It also gives insight into barriers that must be dealt with to improve access Appraisal Summary Key Points Small study. Largest number of participants from Qu, ON, and BC, few from Prairies, maritimes, or territories-lacks their perspectives. Data Extraction Authors Stirling-Cameron, Emma; Carson, Andrea; Abdulai, Abdul-Fatawu; Martin-Misener, Ruth; Renner, Regina; Ennis, Madeleine; Norma, Wendy. Title Nurse practitioner medication abortion providers in Canada: results from a national survey Year 2024 42 Journal British Medical Journal Record # 7 Study Type Mixed methods, cross-sectional, national survey Methodology Mixed methods, cross-sectional, national survey # of participants 181 NPs Characteristics of Participants Roughly half were providing MA. Represented all provinces and territories although 48% were from ON. No NPs in Quebec were providers. Most were 35-44, then 45-54, then 25-34, then 55-66, <5 over 66. Majority of providers urban, non-providers 50-50. Most employed by the province. Less than 12% male. Phenomena of Interest TO report on demographic and clinical characteristics of NPs providing MA in Can and identify barriers and enablers to MA Setting (Culture, geography) Canada Outcomes, Themes & Subthemes Outer Contextual Factors-few providers had encountered protests, however 47% of non-providers were concerned about encountering anti-choice activity. System-able to get u/s within 7 days reported by providers. Community of practice- providers were sig more likely to report having an NP or physician abortion provider working in their community. Interprofessional-Providers more likely to report SA available in their community. More likely to report ongoing communication with local pharmacy. Barriers-logistics, access to protocol, policy restrictions on MA. Access to u/s, mentors, pharmacy Adopters- Providers were more likely to have taken SOGC training. High rates of desire for mentors. Education-reported to be lacking as part of training for all groups. Author’s Conclusions Strengths- First quantitative study documenting barriers and facilitators to the implementation of NP provided MA. Limitations- exploratory nature and convenience sampling. Conducted over covid pandemic so repeated recruitment invitations over 7 months, expanded number of organisations included. Exact number of NPs practicing in this area is unknown so unable to estimate a response rate. Critical Appraisal Was there a clear statement of the aims of the research? Yes, to report on demographic and clinical characteristics of NPs providing MAs, to identify barriers and enablers to the practice. The authors argue to increased NP scope will increase abortion access in primary care therefor there is a need to understand what is impacting uptake of the practice. There was little data on this at the time of the study. Was the methodology appropriate? This was a mixed methods study. Demographic information about participants and barriers and facilitators perceived were collected on a likert-scale survey. This method was appropriate to the aims of the study. Was the research design appropriate to address the aims of the research? Researchers used a survey based on the Greenhalgh et al. (2004) diffusion of innovations theory in order to understand how new practices are taken up in health care. The survey was tested with researchers and clinicians who had experience in MAs to ensure it was appropriate. Was the recruitment strategy appropriate to the aims of the research? To reach the widest number of NPs a survey invitation link was provided to national and provincial healthcare professional organisations and networks, as well as abortion specific professional networks for distribution to members through email and social media. Provided in English and French. Minimum of 2 survey invitations sent. Any NP registered to practice within Canada could participate, regardless of whether they were currently engaged in MA practice. Researchers state that they made several recruitment attempts over 7 months and speculated the survey response was impacted by COVID-19 pandemic and provider strain. Was the data collected in a way that addressed the research issue? Web-based survey. Saturation was not discussed. There was a power calculation and results did reach statistical significance. 43 Has the relationship between researcher and participants been adequately considered? This was not discussed. However the electronic survey was collected and managed by Research Electronic Data Capture (REDCap) so researchers did not have direct contact with participants. Confidentiality was maintained. Have ethical issues been taken into consideration? Ethics approval through Research Ethics boards of Dalhousie University and UBC. Was the data analysis sufficiently rigorous? Yes, descriptive analysis and bivariate comparisons using independent sample t-tests and x-square analysis. Included questions that were not answered by all participants, %s are based on the denominator of participants who answered. Is there a clear statement of findings? Yes, NPs were facilitated to provide MA when they had access to positive communication with local pharmacy, NPs, physicians in community of practice. NPs who were not providing MAs were concerned about lack of access to community of practice, stigma, pharmacy, and other support services. How valuable is the research? This research included NPs from throughout Canada so is applicable nationally. Gives good insights into factors that influence decision to incorporate practice. Appraisal Summary Key Points -Main limitation is exploratory nature and convenience sampling. -COVID 19 pandemic affected response? -Difficult to estimate what percentage of NPs actually engage in MA-is this sample representative? Strengths-national distribution, representative of urban and rural, many practice settings represented. Data Extraction Authors Renner, R., Ennis, M., Kyeremeh, A., Norman, W., Dunn, S., Pymar, H., Guilbert, E. Year 2023 Journal Telemedicine and E-Health Record # Study Type Survey Methodology National, cross-sectional, anonymized, web-based survey # of participants 388 were exclusion for not signing consent, fraud, duplicate, and those that did not provide first trimester abortion. Characteristics of Participants Primary care providers. Most did not work in hospital. Telemedicine was more common amongst those who worked in non-hospital based clinics, had <5 years experience in abortion. Majority under 40 years old. Included NPs and GPs in the same category but did not report individual numbers. Phenomena of Interest Number of first trimester abortion providers who were using telemedicine and perceived barriers to same. Setting (Culture, geography) Highest proportion from BC, lowest from Quebec, but represented providers from all regions of Canada. Majority of respondents lived in urban settings. Outcomes, Themes & Subthemes Majority of PCPs perceived barriers to telemedicine MA. For those who were not providing MA via telehealth barriers reported were lack of access to u/s to confirm gestational age where patients live, inability to order hCG testing, lack of telemedicine equipment. There was not a significant difference in number of barriers perceived between rural and urban respondents. Lack of fee code for telemedicine (Prairies and Ontario) Hospital based respondents reported difficulty accessing mifepristone. Quebec and territories-access to u/s barrier Access to lab testing for hCG, emergency services barrier for territories. Quebec-regulatory barriers. Scheduling Difficulty ascertaining patients mental health status, IPV over the phone. 44 Author’s Conclusions Critical Appraisal Clearly Focused issue? Population-first-trimester MA provider workforce in Canada Risk factors-barriers and lack of equity in abortion care Benefit or harmful effect-barriers to telemedicine Outcomes-inform KT activities to remove barriers and improve equity in abortion access Is the method appropriate? Yes. The researchers modified the Canadian Abortion Providers (CAPS) study to account for recent updates to 2019 guidelines. The survey asked demographic, clinical care, telemedicine and barriers to care questions. Was the recruitment strategy appropriate to the aims of the research? There is no database of abortion providers in Canada so survey invitations were emailed through multiple collaborating health care professional organizations and provided reminds through partners1,2, 4-6 weeks after initial. It is difficult to judge if sample was representative of abortion providers in Canada. All responding abortion providers who completed consent were included. Were the measures accurately measured to reduce bias? Yes, Canadian Abortion Provider Survey, modified from 2012 version to reflect updates to guidelines. Was the data collected in a way that addressed the research issue? Yes, anonymized web survey. Enough participants to minimise play of chance? They did not include a power calculation so this is unclear. How are the results presented and what is the main result? Results are presented as means and medicines with interquartile ranges. It is difficult to estimate how meaningful it is due to unclear number of providers. Bottom line is that the majority of MA providers perceive barriers to telemedicine delivery. Data analysis sufficiently rigorous? R statistical software used to generate descriptive statistics. Inadequate discussion of analysis. Clear statement of findings? Yes, they clearly defined the proportion of MA providers who are engaging in telemedicine and discussed reported barriers. Can results be applied to local population? Yes, because it included representation from all regions of Canada the results are applicable nation wide and addresses issues unique to certain regions. Value of research Authors discuss how this research can inform KT and guideline/policy development. Appraisal Summary Key Points Limitations-inability to determine representativeness of sample. Difficult to estimate response rate. Strength-sampling strategy supported by the interprovincial reatio of respondents. National sample, multi partner recruitment. Data Extraction Authors Carson, Andrea; Stirling-Cameron, Emma; Paynter, Martha; Munro, Sarah; Norman, Wendy; Kilpatrick, Kelley; Begun, Stephanie; Martin-Misener, Ruth Year 2023a Journal PLOS One Title Barriers and enablers to nurse practitioner implementation of medication abortion in Canada; A qualitative study 45 Study Type Qualitiative-semi-structured interviews Methodology CART study modified. # of participants 2 participant groups, 20 stakeholders, 23 NPs Characteristics of Participants Stakeholders working in gov, health administration, nursing regulation and law. 2nd group NPs who had and had not provided MA. Phenomena of Interest To identify barriers and enablers to NP provision of MA Setting (Culture, geography) Attempted to represent all regions of Canada and practice settings. Could not find an NP in Quebec to participate. Outcomes, Themes & Subthemes U/S-enabler that it is not required. Barrier that it is difficult to obtain if needed/if NPs lacked confidence in the process. Advertising-seen as benefit and barrier due to fear of stigma Specialized care- Specialized clinics were source of support (enabler). Perception that MA is specialized made some hesitant to practice Infrastructure/resources- Urban NPs with access to ER, u/s, pharmacy felt supported. NPs in rural or remote locations felt lacking these resources was a barrier. Education & mentorship- mentorship enabler. Unknown pool of other providers was a barrier. Author’s Conclusions Policy and reg changes not enough to make care accessible. Consider resources. Lack of resources continues to limit rural and remote practice. Critical Appraisal Was there a clear statement of the aims of the research? To identify barriers and enablers to NP MA practice Is a qualitative methodology appropriate? Yes, interviews required to explore themes. Was the research design appropriate to address the aims of the research? Yes, modified CART Was the recruitment strategy appropriate to the aims of the research? Purposeful snowball sampling. Stakeholders invited through networks of the research team and knowledg users. Nursing organizations in Can and sexual/reproductive health clinics and members of the Canadian Abortion Providers Support Network (CAPS). Attempted to achieve diversity of sample with respect to rural/remote or urban setting, region of Canada and practice setting. Non-providing NPs were included. Was the data collected in a way that addressed the research issue? Telephone or video-conference for interviews by team trained in qualitative interview methods. French and English. No honoraria Has the relationship between researcher and participants been adequately considered? Participants assigned pseudonyms and contextual details were separated from responses for deidentification Have ethical issues been taken into consideration? Approved by Nova Scotia Health research ethics board and UBC Research Ethics Board. Was the data analysis sufficiently rigorous? Yes, digitally recorded interviews. Translation from English if completed in French. Two researchers read each transcript. Coded to categorize. Meetings to discuss each transcript and codebook developed. Data saturation achieved. Is there a clear statement of findings? Yes, each theme was analyzed for barriers and enablers. How valuable is the research? Adds to discussion of furthering policy and education 46 Appraisal Summary Key Points Data saturation was discussed. No Quebec NPs were found to participate.